Health Insurance & Claims Chapter 2
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| Prospective payment system used to calculate reimbursement for outpatient care according to similar clinical characteristics and in terms of resources required. | Ambulatory Payment Classification (APC)
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| Form used to submit outpatient insurance claims | CMS-1500
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| Provision in an insurance policy that requires the policyholder or patient to pay a specified dollar amount to a health care provider for each visit or medical service received. | copayment (copay)
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| Amount for which the patient is financially responsible before an insurance policy provides coverage. | deductible
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| Reimbursement for income lost as a result of a temporary or permanent illness or injury. | disability insurance
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| Health care coverage available through employers and other organizations. | group health insurance
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| Three or more health care providers who share equipment, supplies, and personnel, and divide income by a prearranged formula. | group medical practices
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| Mandates regulations that govern privacy, security, and electronic transactions standards for health care information. | Health Insurance Portability and Accountability Act of 1996 (HIPAA)
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| Coverage for catastrophic or prolonged illnesses and injuries. | major medical insurance
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| Cost-sharing program between the federal and state governments to provide health care services to low-income Americans. | Medicaid
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| Reimburses health care services to Americans over the age of 65 and patients with End-stage renal disease (ESRD). | Medicare
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| Federal legislation that expanded the Medicare and Medicaid programs. | Omnibus Budget Reconciliation Act of 1981 (OBRA)
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| Designed to help individuals avoid health and injury problems. | preventive services
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| Issues predetermined payment for services | prospective payment system (PPS)
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| Performs utilization and quality control review of health care furnished, or to be furnished, to Medicare beneficiaries. | quality improvement organization (QIO)
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| Based on data collected from resident assessments, using data elements called the Minimum Data Set, or MDS, and relative weights developed from staff time data. | Resource Utilization Groups (RUGs)
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| Payment system that reimburses physicians' practice expenses based on relative values for three components of each physician's services; physician work, practice expense, and malpractice insurance expense. | Resource-Based Relative Value Scale system (RBRVS)
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| Process of the third-party payer recovering health care expenses from the liable party. | subrogation
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| Who other than an insurance company administers health care plans and process claims, thus serving as a system of checks and balances for labor and management. | third-party administrator (TPA)
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